MEDICARE: SHANA ONIELLA JACKSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW16838	FL
2	1041C0700X	Clinical Social Worker	6801107893	MI
3	1041C0700X	Clinical Social Worker	94269	CA
4	1041C0700X	Clinical Social Worker	149020734	IL

General Provider Information

NPI Number	:	1225316581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA ONIELLA JACKSON LCSW

Provider Business Mailing Address
First Line	:	3551 ROGER BROOKE DR
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-4504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 N MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4255
Country	:	US
Telephone Number	:	312-798-9212
Fax Number	:	844-246-6796

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2011
Last Update Date	:	01/09/2026

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